Decisions about Hormone Replacement Therapy for the Peri-menopausal Lesbians

Kate O'Hanlan, MD
Karen Casey, RN, MS, NP
Suzanne L. Dibble, DNSc, RN

On July 9, 2002, the results of a 5 year study of the drug Prempro (combined Estrogen and Progestin) in postmenopausal women were announced. The data safety monitoring board decided that the risks of developing breast cancer outweighed the benefits. Additional findings included a small but statistically significant increase in heart attacks, pulmonary embolus, strokes, dementia and cognitive decline. Therefore, we now have some understanding that this drug should not be automatically given to women just because they are post-menopausal in hopes of preventing these same diseases. This same data safety monitoring board did not stop the ongoing study of Estrogen-only use in postmenopausal women (who had previously undergone hysterectomy) because the drug did not show significant harm to these women.

So what does this mean for peri-menopausal lesbians?
Hormone replacement therapy for the treatment of significant menopausal symptoms continues to be appropriate. The study that was reported last July did not address this issue but others have. Nothing relieves hot flashes better than estrogen. It is also important to understand that the risk for an individual woman should be identified based on years of hormone replacement therapy use after the usual age of menopause (about 51 years of age) rather than the age of the study participants who were ten years older.

So let's talk about menopause. How do estrogen and progesterone affect different organ systems and what role do they play pre, peri, and post- menopausally?

Basic Ovarian Function. During the reproductive years, estrogen is produced in varying amounts on a continuous basis by the cells surrounding the egg follicles in the ovary. Estrogen is released from the tissue surrounding an egg in the ovary for the first two weeks of each month and progesterone is secreted in the second half of a woman's cycle, and signals the uterus and breasts to prepare for a potentially fertilized egg. If no pregnancy occurs, with declining levels of both hormones around day 28 of the cycle, the lining of the uterus sheds as a menstrual period.

Estrogen and progesterone have other important functions as well. Estrogen supports the lining of the upper vagina and maintains a lush wall of tissue to allow secretion of lubrication during sexual excitement. Estrogen, along with testosterone, is responsible to some degree for libido in women. It also supports the back wall of the bladder and urethra and helps maintain strength and continence, preventing bladder infections. Estrogen promotes bone maintenance by inhibiting calcium absorption from the bone. It also induces mild but favorable changes in the cholesterol profile by increasing the High Density Lipoproteins (HDL), the good cholesterol, and decreasing the Low Density Lipoproteins (LDL), the "bad" cholesterol. It is also associated with blood clots (especially in smokers) and is implicated in the higher rates of gall stone formation among susceptible women.

Menopause Defined. Menopause is clinically defined as the time after a woman's period has ceased for at least 12 months. Physiologically, it begins when the ovaries run out of eggs resulting in very low levels of estrogen (20 pg/dl), and no more egg releases. The sudden large drop of estrogen and/or progesterone can result in a variety of symptoms, due to different patterns of hormone secretion slowing or stopping. The most common patterns are 1) a gradual tapering off of both hormones which means less dramatic symptoms, 2) an abrupt cessation of secretion of both hormones which is frequently associated with hot flashes, insomnia, and sometimes changes in mood, and 3) the confusing picture with loss of one hormone while the other continues which can result in hot flashes while still getting regular periods or, on the other hand, could mean a woman has irregular and occasional profuse periods. Other symptoms may include palpitations, and psychological alterations in mood, such as irritability and depression (which may be related to sleep loss due to nighttime hot flashes). Symptoms that usually occur later in the menopause include vaginal dryness, painful sexuality, and urinary incontinence, urgency or infections. The acute symptoms usually go away or lessen in most women after one to five years; however, some 10% of women will continue to have hot flashes throughout their lives after menopause. For some women these symptoms are mild and not bothersome, but for other women, they can be distracting to intolerable, disrupting their lives and requiring treatment for as long as they are present.

In addition to the physical changes mentioned above, there are other changes which are not "felt" by a menopausal woman, such as bone density loss, increased LDL cholesterol, and increased blood clots. These are equally as important as the physical symptoms. Heart disease almost never occurs as a surprise. It usually occurs after twenty or more years of poor lifestyle, and/or elevated risk factors. About 45% of women die of heart disease, which is largely preventable by lifestyle changes. When estrogen levels drop, the cholesterol profile can worsen some, as it can also worsen due to natural aging, lack of exercise, poor diet and obesity. Osteoporosis and Alzheimer's disease are other concerns that women have as they age. Many women erroneously think that hormones should be taken to prevent aging itself, although there is no clinical evidence that this possible. Concerning osteoporosis, estrogen is only one of five therapies that stop bone loss and is indicated for some women with very low bone density.

Healthy lifestyle - First line of protection for menopausal symptoms and other changes

What are the first things to try in managing the symptoms of menopause and to prevent osteoporosis and/or heart disease. With the idea of a healthy lifestyle as the best way to prevent or initially treat most conditions associated with aging and menopause, lesbians of every age should be painstakingly counseled by every one of their health care providers to:

1. Exercise. 30-minute periods of exercise 4 times/ week and weight bearing exercises decrease the risk of heart disease, osteoporosis and many cancers.
2. Stop smoking! Smoking increases risk for heart diseases, osteoporosis and cancers.
3. Drink alcohol in moderation. While one alcoholic beverage a day may be beneficial in preventing cardiac disease, more than one alcoholic beverage daily will increase risk of cancers and osteoporosis.
4. Monitor and maintain an optimal blood pressure, blood sugar and cholesterol very carefully.
5. Maintain an optimal weight (BMI<27, preferably under 25). This will reduce risk of heart disease and stroke.
6. Eat well: A moderate protein intake is associated with lower rates of osteoporosis. A low-fat, high-fiber, predominantly vegetarian diet is the most protective for heart disease, cancer and osteoporosis and facilitate weight managment. In addition, foods or a multivitamin which include the following appear to offer proven health benefits; selenium, Vitamin A, B, C, D and E.
7. Get your Calcium! Calcium intake (calcium carbonate or citrate well-tolerated by most) from both dietary sources and supplements reduces risk of osteoporosis, colon cancer and hypertension. Total intake from both sources should be at least 1000 mg of elemental calcium for women with either endogenous or exogenous estrogen, and 1500 mg for women who do not have or take estrogens.
8. Reduce Stress. Stress related to major life changes, such as menopause for some women, has been linked to increased incidence of heart disease and cancer. Take care of yourself always, but especially at these times to help reduce your stress. Accessing a social network of family and/or friends, relaxation exercises, physical exercise and adequate sleep are all examples of ways to deal with stress.
9. Treat Depression. Depression obviously impairs your quality of life from an emotional perspective but it also affects your physical health and ability to treat/fight physical ailments. If left untreated, depression can affect your heart and circulatory system as well as your gastrointestinal system. There are many ways to treat depression so if you think you're depressed, talk to your health care provider!!
10. Get enough sleep. People require different amounts of sleep at different times but generally 7-9 hours of sleep a night is considered adequate for an adult.

While we're asleep we give our body essential time to replenish itself physically and mentally. Women, however, often report problems sleeping which has been shown to lead to moderately increased risks for heart disease and accidents due to daytime sleepiness among other problems. If you are unable to get enough sleep, try altering your sleep environment. If this doesn't work, talk to your health care provider.

But Dr. Kate, I tried all of those things and my hot flashes are terrible and my partner keeps getting her sleep interrupted…Should I try herbs next?

You can try estrogens which work predictably well or experiment with some of the many regimens for helping the various bothersome symptoms that are available and safe, and offer partial reduction of symptoms. Some patients report that vitamin E (alpha-tocopherol) at 1,000-2,000 I. U. helps their flashes. Soy Bean Extracts, called isoflavones (Promensil 40-80mg or any isoflavone with other name brands, 80 mg), or soy itself in quantities up to 80 grams have relieved hot flashes for some. A trial of natural progesterone, 100 mg daily, has benefited some women. A low-dose progesterone cream can abate some hot flashes. Acupuncture and acupressure have relieved hot flashes for many women. The following herbal formulas can be used only after consultation with a practitioner knowledgeable about herbs and menopause: Two Immortals™, Zhi Bai Di Huang Wan, Osteoherbal™, Zuo Ghi Wan and Er Zhi Wan. Specifically, formulas conatining black cohosh, chasteberry, motherwort, skullcap, false unicorn, licorice, and alfalfa to name a few.

Dr. Kate, I tried all of those things. My hot flashes and sleep are terrible and my doctor mentioned some other drugs that might help with these symptoms?
 
Low-dose Clonidine patches or oral tablets may be used but they have a side effect of low blood pressure. Bellergal has been shown to reduce frequency of hot flashes as well. Effexor is an antidepressant that can reduce hot flashes, and may be a great choice especially if depression is present. Depression is a sometimes a temporary response having a rapid drop in estrogen levels, but persistent or prolonged depression may also be a result of insomnia or hormone loss. Troublesome insomnia can be treated with any of the fast-acting, rapidly metabolized benzodiazepines (Ambien, 2.5-5.0mg).

Dr. Kate, those didn't really help, now what?
 
Many women try to soften the sudden decrease of hormones by using low doses of estrogen for a short while, until symptoms do not recur. Most women will simply gradually stop having periods and many develop hot flashes and sleep difficulties around the age of 51. Some women will have irregular bleeding, sometimes flowing heavily and require hormonal therapy to control the cycles. Some women develop hot flashes while they are still having periods; they usually benefit from very small doses of supplemental estrogens to ameliorate their hot flashes. Combination HRT is probably safe for less than 5 years. Unopposed estrogen for women without a uterus is still considered to be safe indefinitely.

A significant drop in estrogen levels can cause symptoms in early menopause that are disruptive to women's lives, therefore most women will want some form of short-term hormonal therapy. Hot flashes can be debilitating and unrestful sleep can cause depression. But fortunately, these symptoms will abate with the usually prescribed low doses of estrogen. After the body gets used to the lower levels for a few years, the HRT can be discontinued without return of symptoms for many women. It is thought that the symptoms go away either because the body accommodates to lower levels of estrogen, or because when discontinuing the replacement hormones, the drop is so much smaller than the original plummet from the active ovarian secretion levels.
Bothersome systemic symptoms (hot flashes, night sweats, insomnia) amenable to hormone therapy should be treated with the lowest effective dose for as long as they recur in a bothersome manner. For some women, this may mean lifelong HRT so that they can feel normal.

You should feel normal on the HRT, or the dose needs to be adjusted. The goal is to keep you on the lowest dose of estrogen that abates your symptoms and makes you feel normal. The major symptoms of too low estrogens are hot flashes and insomnia. The major symptoms of too much estrogen are tender breasts, bloatiness and hot flashes. While it is not useful to measure the level or estrogen in your body when you are comfortable and feel normal, if you have symptoms but are on a dose that seems right, it may become useful to check a blood level to see if you aren't absorbing it well from your intestines. If hot flashes or insomnia persist, the dose needs to be adjusted or your blood level checked. If you have tender breasts on estrogens alone, the dose is too high and needs to be adjusted down. It is not abnormal to experience tender breasts, and any of the other familiar PMS symptoms while using the combination of estrogen and progesterone since it mimics the natural cycle of these hormones in the menstrual cycle.

Dr. Kate, I'm having a hysterectomy at 40 and my doctor wants to give me estrogen. What should I do?
 
It is not controversial to prescribe hormone therapy to younger women (under age 51) entering the menopause, whose ovaries naturally stopped or were surgically removed. In fact, if the ovaries are removed or shut down for over ten years and low-dose hormones are taken to prevent hot flashes, the breast cancer risk is still reduced by 50%. We do know, however, that the breast and ovary cancer and gallstone risk is not elevated by hormone therapy in women under age 51, the average age of menopause. Here is why: After removal, estrogen levels drop dramatically. To prevent her from having hot flashes and insomnia, she starts estrogen pills, which keep her blood levels higher than without ovaries and but significantly lower than if she had functioning ovaries. This much lower dose is just enough to make her feel normal. So the plan for her would be to take the estrogen pill or patch until she turns 51 or so and then to go off and see how she feels off estrogen, just like other women when their ovaries naturally quit at age 51. It is important to note however that at 51 the clock of estrogen use starts ticking. This is because from 51 on, the average woman's estrogen level has fallen dramatically, causing hot flashes for some who will want short-term hormones to ease the transition. If she takes estrogen after age 51, to keep a moderate level of estrogen and ease menopause symptoms, then her estrogen levels will be higher than the average woman's level in this age group. Research tells us that after 5 years of higher than the average woman's levels, the risk of breast cancer etc. starts to increase. Research also tells us that a woman who has her ovaries removed at age 30 and takes estrogens for 21 years until age 51 has only a 6% chance of breast cancer, half of the regular risk of 12%. In sum, replacement doses are less than ovarian secretion doses, until menopause, age 51, when the average woman's estrogen levels drop below replacement doses.

Dr. Kate, I want to stop my hormones. How do I do this?

It is recommended that women take menopausal hormone regimens for as long as they need them, discontinue using them when no benefit is appreciated or predicted by research, and receive appropriate follow-up surveillance testing once the hormones are discontinued. Most women will notice that their hot flashes disappear after 2-5 years in menopause, either because they forget their hormones for a few weeks or simply forego them for a few weeks and notice no difference. They should stay off the HRT if the hormones make no noticeable difference. In fact, all women on HRT after age 51 should try discontinuing their HRT every year for a few weeks just to see if they still need their HRT. If their symptoms of hot flashes or insomnia recur, restart the HRT. If none are noted, discontinue the HRT.